Familial hypercholesterolemia (FH), a genetic disorder with a prevalence of 0.2%, represents a high-risk factor to develop cardiovascular and cerebrovascular diseases. The majority and most severe FH cases are associated to mutations in the receptor for low-density lipoproteins receptor (LDL-r), but the molecular basis explaining the connection between mutation and phenotype is often unknown, which hinders early diagnosis and treatment of the disease. We have used atomistic simulations to explore the complete SNP mutational space (227 mutants) of the LA5 repeat, the key domain for interacting with LDL that is coded in the exon concentrating the highest number of mutations. Four clusters of mutants of different stability have been identified. The majority of the 50 FH known mutations (33) appear distributed in the unstable clusters, i.e. loss of conformational stability explains two-third of FH phenotypes. However, one-third of FH phenotypes (17 mutations) do not destabilize the LR5 repeat. Combining our simulations with available structural data from different laboratories, we have defined a consensus-binding site for the interaction of the LA5 repeat with LDL-r partner proteins and have found that most (16) of the 17 stable FH mutations occur at binding site residues. Thus, LA5-associated FH arises from mutations that cause either the loss of stability or a decrease in domain's-binding affinity. Based on this finding, we propose the likely phenotype of each possible SNP in the LA5 repeat and outline a procedure to make a full computational diagnosis for FH.

V.E.A. was funded by Banco Santander Central Hispano, Fundación Carolina and Universidad de Zaragoza and was recipient of a doctoral fellowship awarded by Consejo Superior de Investigaciones Científicas, JAE program. M.O. acknowledge financial support from grants BIO2012–32868 (Ministerio de Economía y Competitividad, Spain), 2014SGR00134 (Grups de Recerca Consolidats, Generalitat de Catalunya, Spain) and PT13/0001/0019 (ISCIII, Spain). J.S. acknowledge financial support from grants BFU2010-16297 (Ministerio de Ciencia e Innovación, Spain), BFU2013-47064-P and BIO2014-57314-REDT (Ministerio de Economía y Competitividad, Spain) and PI078/08 (Gobierno de Aragón, Spain). Funding to pay the Open Access publication charges for this article was provided by grant BFU2013-47064-P (Ministerio de Economia Y competitividad).